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        <p>模块19 特定牙位刮治器（Area-Specific Curets)<br>Section1:特定牙位刮治器(Area-Specific Curets)<br>①功能<br>A.用于从牙齿表面去除轻度到中度牙结石。<br>B.特定牙位意味着每个器械被设计为仅用于特定牙齿和特定牙面，因此整口的刮治需要多个器械。<br>②设计特点。<br>A.工作端的表面(face)相对短柄是倾斜的。<br>(1)倾斜度大约为70°。<br>(2)倾斜导致工作端的切割边缘的一侧要低于另一侧。<br>B.每个工作端只有一个切割边缘是可用的。（较低的那一侧）<br>C.一个长的，复杂的功能柄(functional shank)对于牙周袋内的牙根面清创是特别适合的。<br>D.其它的设计与通用刮治器类似：圆的背部，圆的尖端，半圆形的横截面。<br>③常见的特定牙位刮治器：Gracey刮治器系列等。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0114-yxgzjc28/01.png"><br>表面(face)与短柄的关系<br>牙位特异的刮治器的表面与短柄的关系是倾斜的。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0114-yxgzjc28/02.png"><br>工作端的切割边缘的一侧低于另一侧。<br>非工作的切割边缘太接近短柄了。<br>只有较低的一侧切割边缘用于龈下刮治。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0114-yxgzjc28/03.png"><br>技能：识别低的切割边缘（即工作切割边缘）。<br>低的切割边缘远离短柄。<br>只有低的切割边缘用于牙周刮治。<br>高的切割边缘能保护牙周袋的软组织壁，以保护软组织并利于龈下刮治。高的切割边缘不用于牙周刮治。<br>找到低的切割边缘的方法：握持器械，工作端的尖端对向医生，短柄垂直于地面。较低的一侧切割边缘即是。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0114-yxgzjc28/04.png"><br>Gracey刮治器系列<br>Gracey医生在1940年代在豪孚迪工作时设计的。一共14个。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0114-yxgzjc28/05.png"><br>临床上，很少14个刮治器都用到的。实际使用中发现，3个或4个器械刮治全口就够了。<br>Section2:技术练习——前牙(Technique Practice——Anterior Teeth)<br>每个刮治器的工作末端只有一个切割边缘用于龈下刮治。当工作末端贴合于牙面时牙医观察工作末端的表面。如果工作末端贴合于颊面（或舌面），工作末端表面轻微靠向牙齿并且部分不可见时就是对的。<br>前牙正确的选择：工作端表面轻微向牙面倾斜。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0114-yxgzjc28/06.png"><br>不正确的选择：工作端表面远离牙齿。如果如此刮治，器械的工作端可能损伤软组织壁。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0114-yxgzjc28/07.png"><br>前牙的刮治器械选择<br>G1,G2,G3,G4。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0114-yxgzjc28/08.png"><br>上颌前牙<br>应用的牙面<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0114-yxgzjc28/09.png"><br>（以下都默认是右利手者）<br>①牙齿：上颌前牙，牙面：靠近术者。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0114-yxgzjc28/10.png"><br>②准备和插入<br>选择正确的工作末端，放到正确的区域。<br>工作端的尖端应该指向远中面。<br>将工作端插入到袋的基底。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0114-yxgzjc28/11.png"><br>③尖端1/3贴合到中线。想象将器械的尖1/3“锁定”到牙面上。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0114-yxgzjc28/12.png"><br>④在颊面进行刮治。进行一系列短的，精确地刮治用力，通过颊侧表面朝向远颊线角。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0114-yxgzjc28/13.png"><br>⑤在线角区域旋转手柄：轻微旋转手柄以保持尖端1/3在远颊线角区域贴合牙面。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0114-yxgzjc28/14.png"><br>⑥远中牙面：继续向远中，至少通过一半的远中牙面。另外一半从舌侧进入。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0114-yxgzjc28/15.png"><br>⑦用相同的方法刮治前牙区域的其它患牙。从左侧尖牙到右侧尖牙。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0114-yxgzjc28/16.png"><br>⑧变换体位，刮另一侧牙面，从右侧尖牙到左侧尖牙。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0114-yxgzjc28/17.png"><br>Section 3:技术练习——后牙(Technique Practice——Posterior Teeth)<br>至少需要两个双端刮治器。通常需要2-3个。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0114-yxgzjc28/18.png"><br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0114-yxgzjc28/19.png"><br>技能：为后牙刮治选择正确的工作末端。<br>使用短柄作为视觉线索来选择。后牙=平行（Posterior = Parallel）。功能短柄向上覆盖(Functional shank up and over!)<br>后牙远中牙面的选择，短柄平行于远中牙面。<br>功能柄向上覆盖牙齿。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0114-yxgzjc28/20.png"><br>不正确的选择：工作末端的短柄向下环绕前磨牙的颊侧牙面。<br>短柄没有与牙面平行。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0114-yxgzjc28/21.png"><br>下颌右侧磨牙区的刮治。同样只考虑右利手者。<br>（1）从远中牙面开始。右下第一磨牙。使用远中牙面的刮治器。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0114-yxgzjc28/22.png"><br>（2）准备：在远颊线角区域的”准备区域(Get Ready Zone)”放置刮治器。器械的尖端要朝向口腔，因为那是工作区域。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0114-yxgzjc28/23.png"><br>（3）插入：放低短柄并且轻微的沿着牙龈缘倾斜工作端。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0114-yxgzjc28/24.png"><br>（4）通过远中牙面区域。向上抬起手柄，将尖1/3锁定在远颊线角区域。至少刮治远中牙面的一半（另一半从舌侧刮治）。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0114-yxgzjc28/25.png"><br>（5）翻转手柄。使器械在通过远颊线角和在远中牙面时保持贴合。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0114-yxgzjc28/26.png"><br>（6）持续进行刮治。使用一系列短的，精确地力量在远中牙面进行刮治。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0114-yxgzjc28/27.png"><br>（7）通过远中牙面:至少经过远中牙面的颊侧一半。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0114-yxgzjc28/28.png"><br>（8）刮除颊侧和近中。从远颊线角处开始。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0114-yxgzjc28/29.png"><br>（9）准备：在远中准备区域放置器械，尖端指向近中牙面。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0114-yxgzjc28/30.png"><br>（10）插入：器械手柄放低，沿着龈缘稍微倾斜放置工作末端。插入刮治器至袋底。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0114-yxgzjc28/31.png"><br>（11）尖1/3贴合。手柄恢复向上状态，将尖1/3“锁定”在远颊线角区域牙面上。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0114-yxgzjc28/32.png"><br>（12）刮治颊侧牙面。使用一系列倾斜的刮治动作通过颊侧牙面。保持工作端在龈缘以下。将刮治器抽离会损伤龈缘。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0114-yxgzjc28/33.png"><br>（13）继续刮治。使用短的，精确地力量持续刮治整个颊面。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0114-yxgzjc28/34.png"><br>（14）旋转手柄，在抵达近颊线角时，旋转手柄以保持贴合。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0114-yxgzjc28/35.png"><br>（15）技术检查：确保刮治扩展通过近中牙面的中线。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0114-yxgzjc28/36.png"><br>（16）按顺序进行远中牙面的刮治。从最后的磨牙开始到第一前磨牙结束。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0114-yxgzjc28/37.png"><br>(17)按顺序刮治颊侧和远中牙面。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0114-yxgzjc28/38.png"><br>水平刮治在某些区位的牙石去除中非常有用：（1）后牙靠近远颊或远舌线角区域；（2）前牙的颊舌侧中线区域。<br>一步一步刮治上颌第一磨牙：先刮远中，然后颊侧，最后刮近中。<br>Section4：根面刮治技术(Instrumentation Techniques on Root Surfaces)<br>根面刮治的三种用力方式<br>分别为评估用力（“感觉”用力），用于评估根面；牙石去除用力（“工作”用力），用于完全去除牙石；根面清创用力（“完成”用力），平整根面以利于组织愈合。具体见下表<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0114-yxgzjc28/39.png"><br>手的用力方式<br>有三种方式：（1）手指以改良握笔式方法捏的力；（2）支点的手指的压力；（3）刮治期间对牙齿的侧向压力。<br>对持续压力的误用<br>A.新手常常运用持续的稳定的压力以试图控制刮治过程。这会很快消耗肌肉储存的能量并且这也是一个坏习惯。<br>B.研究表明以捏的方式不必要的使用力量是牙科从业人员发生职业损伤的最主要的危险因素。<br>在刮治中使用压力的三个最重要的概念：<br>A.估计(Gauge)压力的量：使用可以完成工作的最小的力量。<br>B.仅使用简短的压力：仅在短期并且仅在刮治过程中——绝不要在刮治之间——使用力量。<br>C.在每次刮治用力后放松：在两次刮治之间，暂停(PAUSE)和放松(RELAX)你的手指。<br>Section5:根面平整(Production of a Root Debridement Stroke)<br>在根面使用多个方向的力<br>经常牙根隐藏在龈缘以下的深牙周袋内，因此，医生看不到牙石。使用多个方向的刮治力可以确保根面的每个平方毫米的地方都能被刮治到。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0114-yxgzjc28/40.png"><br>三种用力方式的混合使用，创造了一个多方向的网格，覆盖了袋底以上的整个根面。三种用力方向依次使用。<br>Section6:设计总览：洁治器和刮治器(Design Overview: Scalers and Curets)<br>略。<br>(总结：这就是全书最重要的内容啦，就是牙位特异的刮治器的辨识和使用。第一，要针对治疗牙位选择正确的器械。第二，要选择正确的工作末端的切割刃，方法：垂直握持器械，尖端朝向自己，选较低的那一侧切割刃。另外对前牙，放入后工作末端靠向牙面而不是牙龈，就是对的。对于后牙，放入并贴合后，器械短柄是与牙面平行，功能短柄向上并且覆盖牙面，就是对的。刮治的时候，一般都是从邻面到颊/舌面，再到另一侧邻面。后牙一般是从远中到近中。通过线角的时候要转动手柄使工作端保持与牙面贴合。邻面要覆盖超过一半的区域。要区分三种不同的用力方式，不要持续用力。）<br>接下来的内容可能就是比较“高级”一些的了。还有6个模块。</p>
<p>我发文章的三个地方，欢迎大家在朋友圈等地方分享，欢迎点“好看”。谢谢。<br>我的个人博客地址：<a href="https://zwdnet.github.io/">https://zwdnet.github.io</a><br>我的CSDN博客地址：<a target="_blank" rel="noopener" href="https://blog.csdn.net/zwdnet">https://blog.csdn.net/zwdnet</a><br>我的微信个人订阅号：赵瑜敏的口腔医学学习园地<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/other/wx.jpg"></p>

      
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